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UC-1-01/19 STATE OF DELAWARE
DEPARTMENT OF LABOR
DIVISION OF UNEMPLOYMENT INSURANCE
P.O. BOX 9953
WILMINGTON, DE 19809-0953
302-761-8482

(DO NOT FILL IN THIS SPACE)
This report is to be filled in and returned to Employer Number___________________
REPORT TO DETERMINE
this office within 10 days of its receipt Ind. Code and Area _________________
LIABILITY AND IF LIABLE
whether or not you are liable for Effective Date of Liability ____________
APPLICATION FOR EMPLOYER
assessment under Part III, Title 19, Assessment Rate ____________________
ACCOUNT NUMBER
Delaware Code. Status Date: _______________________

FILL IN WITH TYPEWRITER OR PRINT IN INK – ALL QUESTIONS MUST BE ANSWERED

1. Name of Employer and Trade Name, if any: 5. Have you:
☐ 1. Started a new business
☐ 2. Purchased a going business (Attach Explanation)
☐ 3. Just begun having employment
☐ 4. Reorganized (Attach Explanation)
1(a). Federal Employer’s Identification Number:
☐ 5. Other (Attach Explanation)

2. Street Address and Telephone Number of Main Office: 6. Ownership Information
Is business publicly traded on the stock market?
Yes ☐ No ☐

If yes, provide name, Federal Employer Identification Number
3. Address to which employer’s report forms and mail are to and stock exchange symbol of controlling entity:
be sent. Outside representative must file a notarized
power of attorney.

If no, complete ownership information below. If more than one
owner, attach additional information. Percentage of ownership
must total 100%.
3(a). E-Mail Address:
4. Have you previously filed an application for a Delaware If owned by another entity, please attach an organizational chart.
U.I. account number? Yes ☐ No ☐
Name:
Social Security Number:
Address:
% of Ownership:
7. On what date did you first have payroll for 8. Are you liable as an employer 9. Do you own or control any other
employees working in Delaware? under the Unemployment employing unit in Delaware?
Compensation Laws in any other No ☐
state? Yes ☐ Account # ______________
7(a). Will gross payroll meet or exceed $1500.00 Yes ☐ No ☐ If you meet the criteria, do you want to
rd th
in either 3 or 4 quarter? Yes ☐ No ☐ combine accounts for rating purposes?
Yes ☐ No ☐
10. State total number of workers in covered employment in Delaware and total payroll by calendar quarter. If unknown, you may
estimate these numbers.
Effective 1/1/96, wages of all corporate officers are reportable.
MARCH JUNE SEPT. DEC.
Employees Payroll Employees Payroll Employees Payroll Employees Payroll
2015
2016
2017
2018
2019

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11. Check form of organization:
☐ Individual ☐ LLC Individual
☐ Partnership ☐ LLC Partnership
☐ Delaware Corporation ☐ Out-of-State Corporation
☐ Non-Profit ☐ Estate or Trust
☐ LLC Corp (Attach Form #8832 or written explanation. Must indicate tax election from list above.)
☐ Other: _________________________________
11(a). Date of Incorporation: _________________________________

12. Nature and location of business in Delaware (indicate in sections a, b, c, d, and e). Please provide the address for the
physical location where the work will be performed in the State of Delaware. (If the employee is working from home please
provide the employee’s residential address). Attach additional sheets if needed.
(a) Street Address (number & name):

(b) City/County: (c) Zip Code

(d) Principal Types of Activity Percent of (e) Principal Products or Services Percent of
(Manufacturer of Wood Furniture, Food Super Market, Total (Leather Gloves, Electric Motors, Total
Truck Rental, Etc.) EXPLAIN FULLY TV Repairs, Etc.) EXPLAIN FULLY

Total 100.00 Total 100.00

13. Will any employee work primarily in Delaware? Yes ☐ No ☐
If yes, skip #13a, go to #14
If no, complete #13a, before going to #14.
13(a). Will any employee perform some work in Delaware? Yes ☐ No ☐
If no, go to #14.
If yes, attach explanation. For each employee who does not work primarily in Delaware, list all states where work is
performed, the state where the base of operations is located, the state from which work is directed, and the employee’s state
of residence.
14. Name, title, address and telephone number of officer or representative to furnish payroll information.

15. Have you acquired the organization, trade or business, or substantially all the assets of another employing unit? Yes ☐ No ☐
If yes, provide the name and Federal Identification Number of the acquired entity.

16. If you have reorganized, has the ownership and management remained substantially the same? Yes ☐ No ☐
17. Has this business paid any individual who it considers to be an independent contractor? Yes ☐ No ☐
17(a). Has the business issued, or does it intend to issue, IRS Form 1099-MISC to any individual? Yes ☐ No ☐
17(b). If you answered yes, please describe the type of work performed.

18. Are you an agricultural employer as per Title 19 §3302(11)? Yes ☐ No ☐
18(a). If yes, will you pay wages of $20,000 or more in any calendar quarter or employ 10 or more individuals engaged in
agricultural labor for some portion of the day for a 20 week period? Yes ☐ No ☐
19. Are you a domestic or household employer? Yes ☐ No ☐
19(a).If yes, will you pay wages of $1,000 or more in any calendar quarter of the year? Yes ☐ No ☐

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NON-PROFIT EMPLOYERS ONLY

20. (a) Please submit the following documents:
(1) Copy of charter or articles of incorporation and by-laws.
(2) Copy of Internal Revenue Status under IRS Code (Sec. 501-a).
(b) Do you have in your employ four (4) or more employees? Yes ☐ No ☐
(c) Do you elect the reimbursement method in lieu of paying assessments? Yes ☐ No ☐
If yes, the department will send you form COM-4069.
(d) Do you wish to make reimbursement with another employer and establish a group account? Yes ☐ No ☐
If yes, list the names and addresses of all employers in the group and the name and address of the group representative who
will act as the agent responsible for the disbursement of timely payments to the State of Delaware.

Additional Address Information

Corporation Headquarters Address:

Training Tax Address:

THIS REPORT MUST BE SIGNED HERE BY THE OWNER OR DULY AUTHORIZED REPRESENTATIVE
It is hereby certified that the information in this report and in any
attached sheets is true and correct, to the best of my knowledge, and is
submitted with the full knowledge that there are penalties prescribed by
law for misstatements. Application will not be processed without an
authorized signature.
(Signature Required)

Title Date
(Business Name)

If you wish to sign up for online tax filing or online employer separation notices (SIDES), please see our website at:
http://ui.delawareworks.com/

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